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Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff consistently prevented, identified, treated and documented skin and wound care for four current patients (#9, #28, #29 and #30) of four current patients with wounds reviewed, and one discharged patient (#35) of one discharged patient reviewed. These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds, and could affect all patients in the facility. The facility identified 12 current patients with pressure ulcers (damage to the skin caused by lying in one position for too long). The facility census was 164.

The severity and cumulative effect of these systemic failures resulted in non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff consistently prevented, identified, treated and documented skin and wound care for four current patients (#9, #28, #29 and #30) of four current patients with wounds reviewed, and one discharged patient (#35) of one discharged patient reviewed. These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds, and could affect all patients in the facility. The facility identified 12 current patients with pressure ulcers (damage to the skin caused by lying in one position for too long). The facility census was 164.

Findings included:

1. Record review of the facility's policy titled, "Wound Care - Skin Care Protocol," dated 03/10/15, showed:
- Risk assessment is done within 12 hours of inpatient admission, using the Braden Risk Assessment (prediction of pressure ulcer risk based on assessment of a patient's sensory perception, skin moisture, activity, mobility, nutrition, and friction/shear).
- To relieve or reduce pressure, use pillows or other supportive devices to keep bony prominence's (area of thinner skin over bone, where position causes pressure) from direct contact with one another.
- Lesions (wounds) are documented in the electronic medical record.

2. Record review of the facility's procedure titled, "Pressure Injury Prevention," dated 03/2015, showed:
- Persistent pressure on bony prominence's obstructs capillary (small blood vessels) blood flow, leading to tissue necrosis (death).
- A deep tissue injury is characterized by a purple or maroon localized area of intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure or shear (sliding of skin across a surface).
- A Stage I pressure ulcer involves intact skin with nonblanchable redness of a localized area, usually over a bony prominence.
- A Stage II pressure ulcer exhibits a partial-thickness (involves some layers of the skin) loss of the dermis (uppermost layer of the skin), appearing as a shallow, open ulcer with a red-pink wound bed without slough (dead tissue, usually cream or yellow in color). It may also appear as an intact or open serum-filled (fluid-filled) blister.
- A Stage III pressure ulcer exhibits full-thickness (through all layers of the skin) tissue loss, where bone, tendon and muscle aren't exposed, and may include tunneling (tunnels that extend beyond the visual surface of the wound).
- An unstageable ulcer exhibits full-thickness (all layers of the skin) tissue loss in which the base of the ulcer in the wound bed is covered by slough, eschar [dry, dark scab, or falling away of dead skin] or both. Until enough slough or eschar is removed to expose the base of the wound, the true depth and stage is undeterminable.

3. Record review of training material used for nursing orientation titled, "Skin Care & Pressure Ulcer Prevention," dated 2016, showed:
- Pressure Ulcer description included the location, stage, tunneling and or undermining (to wear away), color, drainage odor and measurement.
- Upon initial identification, Licensed Nurses were required to document a complete wound description in the Pressure Ulcer field in the Electronic Medical Record (EMR) flowsheet with wound measurements.
- During routine shift assessments, the Licensed Nurse will document skin/wound descriptions. If dressing is in place and not due to be changed, document the appearance of the dressing - dry and intact, drainage present, odor (for example).

4. Record review of the facility's policy titled, "Wound Care," dated 03/10/15, showed:
- All Registered Nurses (RN) are responsible for assessment and evaluation.
- The RN is responsible for notifying the physician of the wound, consulting Wound Services for patients at risk or those with a wound, managing dressing changes and documentation.
- The RN is responsible for referring all patients who score less than 14 on the Braden Scale, or have any wounds, to Wound Services through a computer consult.
- Wound assessment and documentation should include location, size (length, width and depth), drainage (amount, type, color and odor), tissue type in wound base, description of the skin around the wound and the dressing change performed.

5. Record review of the facility's procedure titled, "Assessment, Reassessment & Monitoring of Inpatient Documentation," dated 05/05/17, showed that a RN must perform a comprehensive patient assessment every twelve hours.

During an interview on 08/03/17 at 10:00 AM, Staff W, Wound Care Nurse, stated that wounds should be measured weekly (conflicts with policy).

6. Observation on 08/01/17 at 9:20 AM showed current Patient #9's feet wrapped with ace wraps which covered wound dressings. The patients left foot was pressed against the bed mattress, and not elevated on a pillow. Staff P, RN, was in the room and prepared to administer medications to the patient. Patient #9 asked Staff P if he could have some pain medication and when asked where his pain was at he replied with his wounds (feet). Staff P did not recognize that Patient #9's foot was pressed into the mattress and could have contributed to his pain.

During an interview on 08/01/17 at 10:15 Staff P, RN stated that she did not notice Patient #9's foot was off of the pillow and would go and fix it.

7. Observation and concurrent interview with Staff BB, RN, on 07/31/17 at 2:56 PM, showed current Patient #28 with:
- A foam border dressing on the right wrist and right elbow/antecubital (AC, inside of elbow) space dated 07/27/17 at 2:00 AM;
- A thick, gray/brown, nickel sized scab to the left elbow that was not covered with a dressing; and
- A foam border dressing to the left upper, outer arm dated 07/28/17 at 2:20 PM.
Staff BB, after survey staff questioned the 07/27/17 dates on the right wrist and right AC space dressing, stated that foam border dressings should be replaced every 72 hours and indicated that the dressing changes were past due.

Record review of Patient #28's medical record showed:
- Nursing staff first assessed a left outer elbow skin tear and right inner elbow skin tear on 07/10/17.
- Wound care nurses documented wound progress notes on 07/10/17, 07/13/17 and 07/14/17, but did not include documented assessment of the left outer elbow skin tear, or the right inner elbow skin tear.
- Drainage (amount, type, color and odor), tissue type in wound base and description of the skin around the wound were documented inconsistently.
- A wound care order dated 07/18/17 at 1:31 PM, showed that staff were to wash the right AC space wound and left elbow skin tear with soap and water every 48 hours, then dry and apply foam border dressing.
- Wound care documentation showed that the left elbow skin tear remained open to air (without a foam dressing as ordered) from 07/27/17 at 2:00 AM, until 07/31/17 at 9:13 PM.
- Wound care documentation showed that the right AC space dressing was changed on 07/27/17 and again on 08/01/17.
- None of the wound assessment by nursing or the wound care nurse showed measurements of the wounds.
- There was no order found for the right wrist and left upper arm dressing.

During an interview on 08/01/17 at 1:33 PM, Staff EE, Wound Nurse, stated:
- Initial dressings can be placed by nursing staff based on policy and procedure, until wound care was ordered;
- The policy and procedure did not direct nurses as to how frequently wound dressings should be changed;
- Nurses did not have the ability to write wound care orders;
- When wound care services were consulted, a complete head to toe skin/wound assessment was completed on the patient;
- Wound care orders should be carried out until orders were discontinued;
- Nursing staff did not always follow ordered wound care; and
- Wound care nurses failed to order Patient #28's wound care, likely because it wasn't until 07/18/17 that the record was reviewed thoroughly to see what was and was not ordered.

During an interview on 08/02/17 at 1:26 PM, Staff W, Wound Care Nurse, stated:
- When wounds were assessed by nursing staff, all of the required documentation (per policy) should be documented.
- Wound care orders should be followed.
- When wound care staff assessed a patient, all of the patient's skin was assessed.
- The facility had a high need for wound education.

These findings indicated:
- The patient's skin was not fully assessed by the wound nurse.
- The first documentation of the right AC space and left elbow wounds by the wound nurse was eight days, and three assessments, after the wounds were identified by nursing staff.
- Wound documentation by staff nurses and wound care nurses was incomplete.
- The primary nurse did not know, and other nursing staff did not follow the patient's wound care orders.

8. Record review on 08/01/17 of current Patient #29's medical record showed:
- A Care Plan note dated 07/28/17 (date of admission) at 10:43 PM, which documented that the patient had a tunneling coccyx (tailbone) wound, with a wound hole that was too small to be packed. The wound was cleaned and a foam border dressing was placed over the wound. There was no documentation that the patient's physician was notified of the wound and no documentation of the color, drainage, odor or measurement of the wound.
- An inpatient wound care consult order dated 07/29/17 at 3:49 AM, for an unstageable coccyx pressure ulcer.
- There was no further wound documentation (on 07/30/17, 07/31/17 or 08/01/17) by primary nursing related to the coccyx wound.
- Flowsheet documentation dated 07/31/17 at 11:56 AM, that the patient's coccyx wound was first assessed at that time by Staff W, Wound Care Nurse, and was described as a Stage III coccyx pressure ulcer. The documentation by Staff W did not include the wound color, drainage, odor or measurement.

During an interview on 08/01/17 at 3:10 PM, Staff AA, Clinical Supervisor, stated:
- Wound staging and measurements were the responsibility of the wound care nurse.
- Since Patient #29's wound tunneled, staff should have contacted the physician for orders if wound care staff were not available (over the weekend).
- "I would want the wound care orders to be there for nurses to use".

These findings indicated:
- The physician was not notified of the wound for wound care orders;
- Nursing staff failed to consistently document wound assessments; and
- Documentation by wound care staff was incomplete.

9. Observation on 08/02/17 at 4:26 PM, showed current Patient #30 with a coccyx wound, tennis-ball sized, covered with yellow slough and unstageable. The patient also had skin that had split open (from swelling) in the right and left groin area, which left two open wounds, each approximately four inches long.

Record review of Patient #30's medical record showed:
- A wound care nurse order dated 06/26/17 at 12:31 PM, to cleanse the coccyx wound with soap and water, apply Maxsorb AG (highly absorbent pad which contains silver for healing) to cover the coccyx ulcer, and dress with a foam border dressing every 48 hours.
- Wound care documentation from 06/27/17 through 08/01/17, did not include measurements of the coccyx wound, did not include dressing changes every 48 hours as ordered (one dressing was not documented as changed for 99 hours), or document the use of Maxsorb AG for 14 of 22 dressing changes.
- A wound care nurse progress note dated 07/12/17 at 3:01 PM, which documented that Maxsorb AG was not in place under the foam border dressing as ordered.
- There was no documentation by nursing or by the wound care nurse, of the wounds found in the patient's right and left groin area.
- There was no wound care consult for wound care nurses to assess the right and left groin wounds.

During an interview on 08/02/17 at 1:26 PM, Staff W, Wound Care Nurse, stated:
- When wounds were assessed by nursing staff, all of the required documentation, per policy, should be documented.
- When new wounds were discovered, a consult should be placed in the computer.
- Wound care nurses found wounds that were not previously documented.
- If a patient had any skin or wound concerns, and the wound care nurse was not available, nursing staff should contact a physician.
- Wound care orders should be followed.
- She believed wound ulcer documentation was inconsistent by the nurses.
- The facility had a high need for wound education.

This showed nursing staff failed to:
- Document the patient's wounds according to policy;
- Follow wound care instructions;
- Order a wound care consult for the patient's groin wound; and
- Contact a physician for wound care orders if wound care was not available.

10. Record review of discharged Patient #35's medical record showed:
- The patient was admitted on 11/06/16;
- A Braden Scale dated 11/06/16 (Sunday) at 6:00 PM, documented a score of 10;
- A "Right gluteal (buttock) contusion" (also known as a deep tissue injury) documented on 11/06/16 at 5:50 PM;
- There was no wound care consult for the patient's Braden scale of less than 14 or for the deep tissue injury, that was found on admission;
- Wound documentation dated 11/08/16 at 8:15 PM (first documentation), of an unmeasured coccyx wound, with a "white/gray" wound base;
- A Wound care consult order dated 11/09/16 at 7:52 AM (three days after a Braden Scale of 10 and three days after documentation of a deep tissue injury);
- A wound care note dated 11/09/16 at 9:48 AM, which showed the patient had a Stage I pressure injury to the right heel, and a deep tissue injury to the right gluteal, both present on admission. A wound care order at 9:44 AM, directed staff to apply a foam border dressing over the coccyx and right and left gluteal;
- No wound care nurse follow-up until 11/18/16 at 11:09 AM, where the patient's deep tissue injury was documented as a Stage II pressure injury. A wound care order at 11:05 AM, directed staff to wash the coccyx with soap and wound cleanser, and apply Maxsorb AG to wound and secure with a foam border dressing, every other day;
- Dressing changes and applications between 11/19/16 and 11/28/16 (discharge date), showed inconsistent use of the Maxsorb AG for the patient's wound as ordered;
- No further wound care nurse documentation related to the patient's Stage II coccyx ulcer was found; and
- No wound measurements were documented.

This showed:
- Nursing staff failed to initiate a wound care consult for a Braden Scale less than 14 (10) and for a deep tissue injury found on admission;
- Nursing staff and wound care nurses failed to document wounds according to policy; and
- Nursing staff failed to follow wound care as ordered.




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